Pelvic/Supra-Pubic Pain

I. Problem/Condition.

Pelvic/supra-pubic pain has a wide and varied differential diagnosis. This differential is driven by the overlying structures (skin) as well as the internal organs that populate the pelvic and supra-pubic areas. It is important to understand the quality of the pain (constant versus colicky, dull versus sharp) and consider the time course over which the pain developed. Pelvic/supra-pubic pain results more acutely from trauma, infection, and perforation, while subacute and chronic pain results from inflammatory, lymphatic, and vascular complications. Careful consideration of these structures coupled with labs, imaging, and a thorough examination will allow the hospitalist to narrow a broad differential into a mature differential driven by evidence and pretest probabilities.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

The most common diagnoses of pelvic/supra-pubic pain relate to uterine, gonadal, renal, and bladder complications. The other, less common causes of pelvic/supra-pubic pain, may include primary dermatologic and musculoskeletal problems as well as referred pain and neuropathies related to underlying vertebral and spinal cord complications. Specifically, the most common uterine diseases include pregnancy and dysmenorrhea. Ovarian and fallopian tubal complications include tubo-ovarian abscess, ovarian cyst, endometriosis, salpingitis, and ectopic pregnancy. Common renal causes of supra-pubic pain include pyelonephritis, perinephric abscess, and nephrolithiasis. Finally, uretral/bladder complications include infectious mechanisms of the genitourinary tract such as cystitis, urethritis, and prostatitis.

B. Describe a diagnostic approach/method to the patient with this problem.

A thorough history, as detailed in the section below, is critical to define acuity of the pelvic/supra-pubic pain, as several surgical emergencies may present with it. By understanding the acuity, severity, and characterization of the pain, a targeted physical exam can be performed.

There are several approaches to generating a differential diagnosis list for pelvic/supra-pubic pain. One approach is to consider superficial or referred causes of pain, and then focus on peri-pubic causes of pain. Extra-peritoneal causes of pain include dermatologic diseases such as cellulitis, musculoskeletal causes such as pelvic bone fracture, neuropathies, and referred pain from the gonads in men. Intra-peritoneal and retroperitoneal causes relate to the organs that populate the pelvic/supra-pubic region which includes the ovaries, testicles, bladder, kidney, and uterus.

Once the physician creates a list of differential diagnoses, pre-test probabilities should be assigned to each diagnosis while also taking into account the acuity of diagnoses which cannot be missed. Finally, labs and evidence-based imaging can be ordered. Subspecialists, including Surgery, Urology, Gynecology, and Interventional Radiology, should be consulted if there is clinical suspicion that a procedure is warranted.

1. Historical information important in the diagnosis of this problem.

After considering the location of the pain and the systems involved, it is critical to get a detailed history from the patient that involves the following: frequency of pain, associated symptoms, radiation, characterizing the pain, time of onset, location of pain, duration of symptoms, exacerbating and relieving factors. These descriptors will dictate which organs are most likely to be involved. Key questions would highlight the following:

Colicky pain versus a constant pain would indicate a luminal obstruction. The most common lumen in this region include fallopian tubes (salpingitis), ureters/urethra (nephrolithiasis), and uterus (dysmenorrhea). Conversely, constant pain versus colicky pain would suggest disease of a solid organ (perinephric abscess, tubo-ovarian abscess, fibroids) or a lumen that has become obstructed.

Surgical history. Adhesions may be causing the pain or may represent another post-operative complication.

Recent trauma. Perforation of bowel, testicular torsion.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

The physical exam for a patient with pelvic/supra-pubic pain is in two parts: the first part of the exam consists of evaluating the supra-pubic region, including a basic abdominal exam which is described in another chapter. The second part is a genitourinary (GU) exam for either a man or woman.

When performing a supra-pubic exam, the patient must be draped in order to expose the suprapubic region, lying flat on the bed with his/her knees bent, and feet flat in order to relax his/her abdominal muscles. First, visually inspect the supra-pubic and lower abdominal area for trauma, lesions, bruises, veins, and surgical scars.

Second, auscultate the lower abdomen - listen for absence/presence of bowel sounds. Next, lightly palpate the lower abdomen and supra-pubic areas. If any masses are appreciated, proceed with a deeper palpation to characterize the size. If the patient exhibits any sign of rebound or involuntary guarding, this is highly concerning for an acute abdomen and surgery should be consulted immediately.

Palpating the kidneys is not always possible; however, you can assess if they are edematous or swollen by forming a fist and lightly tapping on the costoverterbral border on the left-side of the back. If costovertebral angle (CVA) tenderness is present, this may suggest pyelonephritis or perinephric abscess. Finally, percuss the lower abdomen; tympanic sounds indicate air in the bowel. A dull sounding abdomen is consistent with stool filled bowel, ascites, or an abdominal mass.

The GU exam for a woman consists of a speculum exam followed by a bimanual exam. When completing the speculum exam, the physician must pay attention to mucosal abnormalities, presence and characterization of vaginal secretion, and inspection of the cervix. Endocervical cultures should be obtained. During the bimanual exam, cervical motion tenderness and adnexal tenderness are most commonly associated with pelvic inflammatory disease (salpingitis, tubo-ovarian abscess). Presence of an adnexal mass may suggest ovarian torsion or tubo-ovarian abscess. The GU exam for men is addressed in a separate chapter.

Both men and women should undergo a rectal exam; a tender prostate indicates prostatitis in men; a bloody examination in women may indicated invasion of the intestinal lumen due to endometriosis.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Imaging

Imaging is critical to characterizing the possible causes of pelvic/supra-pubic pain. Choosing the correct imaging modality based on your pretest probability is essential. The most important consideration for any woman of child bearing age is to first obtain a urine pregnancy test; a positive result will limit the imaging modalities available to the physician. Many of the imaging modalities related to gynecologic diagnoses are of limited value and often require more invasive methods to make a definitive diagnosis. The modalities and indications include the following:

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

Transvaginal ultrasound may not be tolerated or of limited use in certain patients. Thus, additional modalities such as transabdominal ultrasound, CT Scan, or MRI may yield more sensitive and specific results.

ESR and CRP are sensitive, but non-specific criteria used in the diagnosis of PID.

PSA - The evidence of PSA as a screening test is controversial. However, use of PSA along with a digital rectal exam is evidence-based per the American Urology Association.

CA125 - Not a useful screening test for ovarian cancer. However, it is useful when used in conjunction with an ultrasound in assessing postmenopausal women with ovarian cysts.

A. Management of Clinical Problem Pelvic/Supra-Pubic Pain.

Early goal directed therapy with fluid resuscitation and cardiovascular stabilization.

All patients should remain NPO until clinical stability is determined and appetite returns.

Perform a urine pregnancy test immediately if patient is of child bearing age.

Assess if patient has an acute/surgical abdomen/pelvis. During the initial examination of the patient, the most emergent considerations are ectopic pregnancy, tubo-ovarian abscess, pyogenic nephrolithiasis, testicular torsion, atypical appendicitis, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, and acute abdomen secondary to another diagnosis such as perforated viscera.

Emergent imaging should include the most critical and likely diagnoses. Pelvic ultrasound is a cheap, easy test to perform that does not expose a potential fetus to radiation. Additionally, it is the preferred imaging modality when a gynecologic etiology is suspected. Abdominal and transvaginal ultrasound may help diagnose ectopic pregnancy, endometriosis, tubo-ovarian abscess, pelvic inflammatory disease, ovarian cysts, pyelonephritis, pyogenic nephrolithiasis, and perinephric abscess. However, additional imaging with CT, or more invasive procedures such as laparoscopy are often needed for a definitive diagnosis. CT is more useful when GI or urinary tract pathology is more likely.

Prompt Gynecologic consultation is also recommended in the Emergency Department if ectopic pregnancy is suspected. Additionally, Surgery or Urology consultation may be needed if the patient has an acute abdomen secondary to atypical appendicitis, perforated bowel, enteric fistulization, or testicular torsion. Interventional Radiologists may offer treatment options such as percutaneous drainage (perinephric abscess).

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

Immuno-compromised and elderly patients do not present typically for many of the diagnoses described above. Given their weakened immune system and their inability to mount a sufficient response to infection, the physician must always consider this when making a diagnosis.

IV Antibiotic choices for pelvic / supra-pubic pain must initially include broad coverage for gram positive (including MRSA), gram negative (double cover Pseudomonas if indicated), and anaerobic bacteria. Once a source is identified and speciated, the regimen can be further refined.

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